Drug category	Recommendation
ACE inhibitors and ARBs	May cause hyperkalemia in the presence of renal failure and should be avoided or used only with great caution in patients with serum creatinine levels higher than 2.5 mg per dL (220 μmol per L), glomerular filtration rates of less than 30 mL per minute per 1.73 m2, or potassium levels higher than 5.0 mEq per L (5.0 mmol per L) Both are contraindicated in patients who are pregnant and in those with bilateral renal artery stenosis, unilateral renal artery stenosis with solitary kidney, or allergies; angioedema can occur in rare cases
Beta blockers	May be used in patients with heart failure caused by systolic dysfunction and who do not have contraindications (e.g., allergy, bradycardia, hypotension, severe reversible airway disease) Should be added when patients are stable to arrest the progression of the disease; they are not to be added as rescue therapy for patients who are decompensating Start at low dosage and double every two to four weeks as tolerated until target dosage reached; stop upward titration if patient is intolerant of higher dosages Absolute contraindications include heart block, bradycardia, and severe reversible airway disease Relative contraindications include rest dyspnea with signs of congestion and hemodynamic instability; once these issues have resolved, beta blockers may be added to the chronic regimen
Aldosterone antagonists	Risk of hyperkalemia may be significant, especially among patients not meeting clinical trial entry criteria; these risks can be minimized by ensuring appropriate patient selection before initiating treatment and by avoiding use in patients with glomerular filtration rates of less than 50 mL per minute per 1.73 m2 or serum creatinine levels higher than 2.5 mg per dL Electrolytes should be monitored closely; elevation of potassium to a level of 5.0 to 5.5 mEq per L should prompt dosage reduction or drug discontinuation
Isosorbide dinitrate and hydralazine	These medications are available as a fixed-dose combination in branded form (Bidil); generic constituents should be just as effective and are much less expensive Clinical trials were performed using isosorbide dinitrate; isosorbide mononitrate (Monoket) is dosed daily and is more convenient; evidence of clinical equivalence of the mononitrate form is only per expert opinion Cannot be used concomitantly with phosphodiesterase inhibitors (e.g., sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra])
Diuretics	Although not specifically tested in clinical trials, diuretics should still be used as needed for volume overload Diuretics were consistently part of background therapy in published placebo-controlled mortality trials of symptomatic patients in which ACE inhibitors, beta blockers, and aldosterone antagonists were studied ACE inhibitors and beta blockers may reduce the need for diuretic therapy
Combining drugs	Pharmacologic treatment described in Table 1 is the desired end point No data are available to indicate how best to introduce all of these medications; however, all major trials added beta blockers or spironolactone (Aldactone) to background therapy with ACE inhibitors, diuretics, and, sometimes, digoxin Many medications appropriate for heart failure (ACE inhibitors, ARBs, aldosterone antagonists, digoxin) can affect potassium levels or can be affected by potassium levels and renal function; vigilant monitoring is required ACE inhibitors, beta blockers, spironolactone, and ARBs should not be removed if symptoms improve because these medications slow disease progression and decrease mortality
Referral	Consider referral for the following clinical situations: diagnostic or revascularization procedures, ventricular arrhythmias, valvular heart disease, worsening or refractory heart failure, or consideration for transplantation